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Teeth and gums: The root cause

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Oncologists and heart specialists rarely bother to look at the state of their patients' teeth and gums-and yet, a growing body of research has discovered that that's the very first place they should be looking

Oncologists and heart specialists rarely bother to look at the state of their patients' teeth and gums-and yet, a growing body of research has discovered that that's the very first place they should be looking.

Researchers are discovering that gum diseases such as gingivitis, when the gums become inflamed and bleed, and the more severe periodontal disease, which can even attack the jawbone, are not only indicators of systemic and chronic disease, but may also be a significant, and unsuspected, cause of the disease.

The association is being made with a range of health problems, including diabetes, cancer, heart disease, birthing problems and mental decline. Indeed, the health of our teeth and gums may even determine how long we live.

Although this breakthrough discovery has occurred only in the past three years, the idea that the health of our teeth and gums can be directly linked to specific diseases was most famously mooted by Dr Weston A. Price (1870-1948) around 60 years ago.

Price, who was appointed the first research director of the American Dental Association in 1914, also argued that root-canal fillings caused the leakage of bacteria that, he believed, could lead to arthritis and other auto-immune diseases. Researchers, however, were unable to find any such association when they fol-lowed up on the theory 20 years later (J Am Dent Assoc, 1951; 42: 615-97).

Price's work, which was sum-marized in his book Nutrition and Physical Degeneration (La Mesa, CA: Price-Pottenger Nutrition Foundation, 2008), first published in 1939, was one of the inspirations for the field of holistic dentistry, which promotes the theory that dental health determines overall health. Nevertheless, until recently, it was practised with very little supportive evidence.

In spite of this, holistic dentists have had a champion in Dr Robert Genco, professor of oral biology at the State University of New York in Buffalo, and editor of the Journal of Periodontology.

As Dr Genco says: "Patients think of gum disease in terms of their teeth, but they don't think about the fact that gum disease is a serious infection that can release bacteria into the bloodstream.

The end results could mean additional health risks for patients whose health is already affected by other diseases, or lead to serious complications such as heart disease."

What came first?

Critics of the theory argue that the health of our teeth and gums is merely symptomatic of our overall health, and inflamed and bleeding gums are a sign of a compromised immune system that, in turn, can lead to systemic illnesses. It's something that especially affects people from poor communities, where personal welfare and a good diet are not always possible.

A study of 282 poor people living in villages in Vukovar, Croatia, confirmed that socioeconomic factors are a significant cause of periodontal disease, but it also raised another factor-stress. The research team, from the University of Zagreb, questioned the villagers about their health and dental care in the five years following the end of World War II, and determined that stress suffered by those during the war and directly afterwardswas a "significant risk factor" for periodontal disease (Eur J Med Res, 2008; 13: 100-6). The socioeconomic argument was also used recently by Cancer Research UK in response to a study which suggested that gum diseases may be associated with a 14-per-cent increased risk of any type of cancer. The group's health infor-mation manager Hazel Nunn said:

"This study doesn't confirm whether it is gum disease or other factors that are causing this increase in risk. Deprivation may play a role as people from deprived backgrounds are more likely to have both poor dental health and poor overall health" (The Daily Telegraph, 26 May 2008).

But an important meta-analysis from the Harvard School of Public Health revealed that the asso-ciation was still evident even after allowing for poverty and depriva-tion. This led the researchers to conclude that "these associations [between periodontal disease and systemic illnesses such as cancer] persist after adjustment for major risk factors, including cigarette smoking and socio-economic stat-us" (Cancer Causes Control, 2008; e-pub 14 May 2008, ahead of print).

In fact, this conclusion has been supported by other reports that involved, as part of their scientific methodology, adjustments for con-founding factors such as lifestyle-including smoking and drinking-as well as a review of the patient's history of the disease and socio-economic status.

In fact, several researchers have gone even further. Not only are they willing to state that there is an association between the health of the mouth and gum disease, but they are also echoing Dr Price's hypothesis that periodontal prob-lems may well be a direct cause of other systemic illnesses.

The inflammation theory

Some dentists who accept the association between gum health and systemic disease nevertheless argue against the cause-and-effect theory. Instead, they believe that the common factor between cardio-vascular disease in particular and gum health is an inflammatory disorder, which may simply be affecting both parts of the body at the same time (Oral Dis, 2008; 14: 102-4).

This idea appears to be support-ed by a study from the University of North Carolina that reviewed the health of 775 women who were, at most, 26 weeks into pregnancy.

Of these, 31 went on to develop preeclampsia (pregnancy-induced high blood pressure, with protein in the urine and swelling due to fluid retention)-and most of these women also had advanced perio-dontal disease. They also had high levels of C-reactive protein, a marker of inflammatory disease (Am J Obstet Gynecol, 2008; 198: 389).

Also, there appears to be some association between periodontal disease and other inflammatory conditions such as endometriosis and rheumatoid arthritis. In one study of 4136 women suffering from endometriosis, researchers discovered that 57 per cent also had gingivitis and periodontal disease. Overall, they concluded that gum disease had evidently increased the risk of endometriosis (Fertil Steril, 2008; 2 April 2008, e-pub ahead of print).

Researchers found a similar connection among rheumatoid arthritis sufferers. In a study of 39 patients in Brazil, they found that the typical patient had fewer teeth, and higher levels of dental plaque and gum disease, than found in the general, non-rheumatic population (Braz Oral Res, 2008; 22: 72-7).

However, researchers from the University of Marseille in France discovered that periodontal disease is a factor of coronary artery disease that is independent of inflammation. When they used coronary angiography to evaluate 131 heart patients, they found a direct link between the severity of periodontal disease and the presence of cardiovascular disease, irrespective of C-reactive protein levels and inflammation (J Intern Med, 2008; 263: 644-52).

Periodontal disease and the heart

The tide only began to turn in favour of holistic dentistry as recently as 2005, when a landmark study discovered that people with gum disease were more likely to develop atherosclerosis, or narrow-ing of the arteries. American researchers at the University of Minnesota took samples from the mouths of 657 healthy volunteers, and found that early signs of atherosclerosis were present in those who were carrying the type of bacteria that cause periodontal disease, a problem that affects up to half of the US population to some degree. The study found that the early signs of atherosclerosis were greatest in those who had 11 or more strains of the bacteria known to cause periodontal disease (Circulation, 2005; 111: 576-82).

In another study carried out to investigate 161 patients, aged 40 to 75 years, with severe angina pectoris and to compare them with 162 healthy controls, researchers found that those with severe periodontal disease were nearly six times more likely to also suffer from chronic heart disease, even after controlling for age and smoking (J Clin Periodontol, 2008; 35: 199-205).

Periodontal disease and cancer

The health of our teeth and gums may also determine whether or not we develop cancer. A recent study suggests that people with persist-ent gum disease have a 14-per-cent higher risk of developing tumours of any sort.

The research team, from Imperial College London, made the discovery after tracking the health of 48,375 men for an average of 17.7 years. Of the5720 men who developed cancer during that period of time, the scientists found that persistent periodontal disease, including gingivitis, increased the risk of kidney cancer by 49 per cent and pancreatic cancer by 54 per cent.

However, the team was unable to establish whether or not gum disease was the actual cause of the cancers or was, instead, only an indicator of an impaired immune system in general, possibly as the result of poverty or poor living conditions (Lancet Oncol, 2008; 9: 550-8).

Periodontal disease and diabetes

Researchers have also concluded that periodontal disease may well be a predictor-and possibly even a cause-of type 2 diabetes, usually considered to be a lifestyle disease.

Scientists at Columbia University in New York tracked the health of 9296 participants who did not have diabetes at the start of the study. After 21 years of follow-up, 53 per cent had developed periodontal disease to some degree, which was classified as level 1 to 5 in terms of severity. While a diabetes risk was not detected in those with early-stage levels 1 or 2, those with more advanced periodontal disease (levels 3 to 5) were more than twice as likely to become diabetic. In addition, participants who had lost some of their teeth were 1.7 times more likely to have diabetes (Diabetes Care, 2008, e-pub 4 April 2008 ahead of print).

In a study of 52 pregnant women, researchers from the Johannes Gutenberg University in Mainz, Germany, found a direct correlation between periodontal inflammation and type 1 (insulin-dependent) diabetes. Those who needed higher doses of insulin were also the ones who had more severe periodontal problems (Coll Antropol, 2008; 31: 115-8).

Periodontal disease and birthing problems

The state of teeth and gum disease appear to affect birth outcomes, an association that is more apparent in developing countries where oral health in impoverished commun-ities is more likely to be poor. Researchers at the Aga Khan University in Karachi, Pakistan, estimate that a woman is 1.3 times more likely to experience a birth complication-such as preterm delivery, low birth weight or still-birth-if she has severe periodontal disease.

They arrived at this conclusion by assessing the dental records of 1152 women who were at least five months pregnant. Of these, 76 per cent had periodontal disease, and there was a direct association between the severity of the disease and the risk of prob-lems at birth. The research-ers concluded that gum disease is a direct cause of birthing problems, and not merely an indicator of general poor health that may lead to a difficult birth (Am J Obstet Gynecol, 2008; 198: 514).

Periodontal disease may also be a cause of preterm delivery, researchers from the University of Sassari, in Italy, have suggested. "There is emerging evidence of a pos-sible relationship between maternal periodontal dis-eases as a potential risk factor of adverse pregnancy outcomes, like preterm low birth weight," they concluded (Minerva Stomatol, 2008; 57: 233-50).

Periodontal disease and pneumonia

People who complain of having a 'sticky mouth', one symptom of gum disease, are known to be twice as likely to develop pneumonia. A group of 4139 Japanese adults,aged 40 to 79, filled out a question-naire that identified periodontal disease from a range of descrip-tions such as 'sensitive teeth', 'difficulty in chewing tough food substances' and 'mouth feels sticky'. Aside from the direct association with pneumonia, gum disease may also be related to cardiovascular disease, again independently of socioeconomic factors (J Dent Res, 2008; 87: 485-9).

Periodontal disease and mortality

Healthy gums and teeth can also determine our degree of disability in older age and even how long we are likely to live. In a study of 573 individuals aged 70 in 1984, researchers discovered that those who had no teeth, or had between one and nine teeth, went on to suffer disability at ages 75 or 80. Those who were completely tooth-less were also 1.26 times more likely to die within the next 21 years than those who still had more than nine teeth at age 70. The study authors, from the University of Copenhagen, concluded that tooth loss is "independently asso-ciated" with disability and mortal-ity (J Am Geriatr Soc, 2008; 56: 429-35).

Periodontal disease and mental decline

One study found a direct correla-tion between oral health and mental cognition. Researchers from West Virginia University in the US examined the dental health of 1984 adults living in care commu-nities, and found that those who had lower cognitive scores also had a higher number of decayed and missing teeth-and more perio-dontal problems. Using a scoring system to establish cognitive ability, the scientists found that the mental score decreased one point for every missing tooth or level of periodontal problems (J Gerontol A Biol Sci Med Sci, 2008; 63: 495-500).

Researchers at New York University have even proposed the theory that Alzheimer's disease may be linked to periodontal disease. They suggest that treating a patient's gum disease may help to modify and control the onset and progression of Alzheimer's (J Alzheimers Dis, 2008; 13: 437-49).

An holistic way forward

Understanding the significance of gum disease as a cause of other serious disease may be one of the most significant breakthroughs in healthcare in years. While socio-economic factors and the general inflammation theory may explain some cases, there is nevertheless enough evidence to support Weston Price's initial idea that periodontal problems are an independent and direct cause of many chronic and systemic diseases.

Although more research is always valuable, the correlation has now been established beyond reasonable doubt. This means that it's now time for doctors to start changing the way they approach disease, especially heart problems and diabetes.

Bryan Hubbard

A diet for healthy teeth

Here are some dietary pointers to help you improve the health of your teeth and gums. These are based on the research work of Melvin Page, Weston Price and Francis Pottenger which, in turn, has been the basis of many of today's dietary regimes.

- Protein. Eat small amounts of protein regularly-around 2-4 oz per serving per meal are ideal-which should comprise young red meat such as veal and lamb, or fish or fowl. If you are vegetarian, eat eggs. Do not heat meat above 110 degrees F as crucial enzymes will then be damaged. Avoid frying in oil or grease.

- Vegetables. Eat these as often as possible and, ideally, raw or lightly cooked. Vegetables should be crunchy and organic whenever possible.

- Fruits. Eat one fruit at a time and on an empty stomach. Avoid the sweetest types and tropical fruits-except papaya and pineapple, which are rich in digestive enzymes. Eat only fresh and organic fruit.

- Carbohydrates. Ideally, vegetables should be your carbohydrates. Limit all grains as much as possible and avoid, at all costs, white bread. The only bread that is acceptable is 100% rye. The only grains allowed in Price's dietary protocols are brown rice, unprocessed rye and rolled oats.

- Fats. Only cold-pressed extra virgin olive oil, walnut oil, flaxseed and grapeseed oils should be used. These oils should never be heated or used in cooking. Avoid all hydrogenated and partially hydrogenated fats, including all margarines, and avoid peanut butter. Instead, eat avocados and raw nuts.

- Dairy. All dairy products from cows are to be avoided. Page maintained that milk is even more detrimental than sugar. An acceptable substitute is raw goat and sheep cheeses and milk.

- Liquids. Drink plenty of water every day. The ideal amount is a half-ounce of water for every pound of your weight. If you must drink wine, drink it only at mealtimes and only red wine. Avoid all Californian varieties.

- In general, it's better to eat little and often than to eat one or two heavy meals each day. Ideally, have three to five small meals every day, and drink fluids one hour before meals and two hours afterwards.

Natural ways to fight tooth plaque

Essential oils and hot water are two natural-and effective-ways to remove dental plaque.

In a meta-analysis involving 11 studies, researchers found that a mouth rinse containing essential oils was effective against dental plaque and early-stage gingivitis. In the studies analyzed, all of which lasted for at least six months, such a mouth rinse achieved a "significant reduction" in gingivitis when tested against controls, and was even more effective than just flossing. A similar pattern was also seen for plaque reduction (Evid Based Dent, 2008; 9: 18-9).

In another study, scientists found that hot water was more effective than toothpaste when it comes to removing plaque from teeth. They also tested various techniques on plaque that was also stained.

They discovered that brushing with running hot water was more effective than brushing with running cold water, and was even better than using toothpaste (Clin Prev Dent, 1991; 13: 29-31).

Essential oils and hot water are two natural-and effective-ways to remove dental plaque.In a meta-analysis involving 11 studies, researchers found that a mouth rinse containing essential oils was effective against dental plaque and early-stage gingivitis. In the studies analyzed, all of which lasted for at least six months, such a mouth rinse achieved a "significant reduction" in gingivitis when tested against controls, and was even more effective than just flossing. A similar pattern was also seen for plaque reduction (Evid Based Dent, 2008; 9: 18-9).

In another study, scientists found that hot water was more effective than toothpaste when it comes to removing plaque from teeth. They also tested various techniques on plaque that was also stained.

They discovered that brushing with running hot water was more effective than brushing with running cold water, and was even better than using toothpaste (Clin Prev Dent, 1991; 13: 29-31).

Is the tooth-decay theory wrong?

If having healthy gums and teeth is so vital to our overall health, what's the best way to prevent tooth decay?

People who consume large amounts of acrylamide-a chemical commonly found in chips, crisps, bread and coffee-could have an increased risk for kidney cancer.

Dutch scientists analyzed data from the Netherlands Cohort Study on diet and cancer from more than 120,000 men and women, aged 55 to 69. Taking a random sample of 5000 people, their acrylamide intake was estimated from a questionnaire and chemical analysis of all relevant Dutch foods. Compared with those who consumed the lowest amounts of acrylamide (9.5 mcg/day), those consuming the highest levels (40.8 mcg/day) had a 59-per-cent greater risk of kidney cancer (Am J Clin Nutr, 2008; 87: 1428-38).

These troubling findings come just months after the same scientists reported a link between dietary acrylamide, and ovarian and endo-metrial cancers. Using the same database and study design, they found that the risk of ovarian and endometrial cancers in women rose with increasing acrylamide intake. Among non-smokers, those who consumed the highest amounts of acrylamide (40.2 mcg/day) had twice the risk of endometrial or ovarian cancer compared with those consum-ing the lowest levels (8.9 mcg/day) (Cancer Epidemiol Biomarkers Prev, 2007; 16: 2304-13).

These and other recent findings have led US health watchdog the Food and Drug Administration (FDA) to update its information and advice on acrylamide.

But what exactly is this compound and what is it doing in our food?

Acrylamide is classified as a probable human carcinogen, and is used in cosmetics, plastics and food packaging. Cigarette smoke and occupational exposures were thought to be the main sources of exposure to it. However, researchers in Sweden discovered that acrylamide is present in a wide range of commonly consumed foods, particularly high- carbohydrate foods that are fried or baked (Int J Cancer, 2004; 109: 774-6; J Agric Food Chem, 2002; 50: 4998-5006).

The findings sparked international concern, and were subsequently verified by scientists in the UK, US, Netherlands, Switzerland and Nor-way. It's turned out that acrylamide is a natural byproduct of cooking certain foods at high temperatures-whether at home or in commercial production. It starts to develop in foods cooked at 120o C (248^0 F), although the optimal range for it is 140-180o C (284-356^0 F). Also, the hotter and longer you bake or fry, the more acrylamide is formed (BMJ, 2002; 325: 120).

Foods that contain the toxin include crisps, chips, fried, baked or roasted potatoes, cereals, crisp-breads and even coffee. Boiling, steaming and microwaving does not appear to produce acrylamide.

A cause of cancer?

Despite the recent research from the Netherlands showing an association between acrylamide and certain types of cancer, it is still not clear that the relationship is causal. Epidemiological studies (such as the ones mentioned here) cannot confirm cause and effect. Moreover, much of the human data on acryla-mide is conflicting. Although one of the latest studies found a link between dietary acrylamide and kidney cancer, two earlier studies did not (Int J Cancer, 2004; 109: 774-6; Br J Cancer, 2003; 88: 84-90). One recent study found a possible link between acrylamide and breast cancer (Int J Cancer, 2008; 122: 2094-100), yet another did not (Cancer Epidemiol Biomarkers Prev, 2007; 16: 2304-13).

Nevertheless, acrylamide (albeit in high doses) can cause cancer in animals, and nerve damage in humans (www.cfsan.fda.gov/~dms/ acryfaq.html), so do we really want to be consuming this chemical under any circumstances?

The advice from health officials is not to eliminate acrylamide-contain-ing foods from the diet, but to continue to eat a healthy, balanced diet, including plenty of fruit and vegetables, bread, other cereals and potatoes, and to limit sugary and fatty foods, including fried foods such as chips and crisps. The UK Food Standards Agency (FSA) notes that such a healthy diet is protective against some cancers.

Fortunately, the US FDA offers more useful advice, based on recent research, on how to reduce acryl-amide levels in your diet:

- Soak raw potato slices in water for 15-30 minutes before frying or roasting. This helps to reduce acrylamide formation during cooking. (Soaked potatoes should be drained and blotted dry before cooking to prevent splattering or fires.)

- Don't store potatoes in the fridge. This can result in increased acrylamide during cooking.

- Cook cut potato products such as chips to a golden-yellow colour rather than brown. Brown areas tend to contain more acrylamide.

- Toast bread to a light-brown colour rather than a dark brown. Very brown areas should be avoided as they contain the most acrylamide.

- Limit coffee intake. Acrylamide forms in coffee when the beans are roasted, not when it's brewed and, so far, scientists have failed to find any effective ways to reduce acrylamide in coffee.